Discordance between clinical and immunological ART eligibility criteria for children in Malawi

BACKGROUND: Since May 2014, all HIV positive children aged less than five years in Malawi are eligible for ART. For children older than five years they are eligible if they are in WHO stage III/IV, if stage I/II, if their CD4 < 500 cells/mm(3). Our goal was to compare the WHO clinical classification criteria (WHO stage + CD4/age) to CD4 count (CD4/age) on all children. Prior to 2014, children aged 2–5 years in stage I and II were eligible for ART if their CD4 was < 750 cells/mm(3). We were interested in the increase in numbers of children in this age group who now meet the eligibility criteria and their average CD4 count. METHODS: Data including age, stage and CD4 count were used. We examined the effect of using two different criteria; WHO staging and checking CD4 count if stage I or II versus CD4 count on all, on the numbers of children eligibility for ART in a cohort of 969 children aged 0 to 14 years in Blantyre, Malawi. RESULTS: Using WHO stage + CD4/age, 786 patients out of 969 would have been treated and 183 would not. Using CD4/age, 745 patients out of 969 would have been treated and 224 would not. Within the 224 patients not treated by CD4 classification, 41 were clinical stage III or IV. The most common staging condition in these 41 children was low weight for age (i.e. underweight). 41% of children age2-5 years have a CD4 count >750. CONCLUSION: Most children are correctly started on treatment using recent guidelines. 41% more children <5 years will be started on ART.